Bloomberg Businessweekunspoken component of every general practice: “Somebody
comes in, and they say, ‘Doc, I’m tired all the time, and I’m
gaining weight, I’m not sleeping well, and I just don’t feel good.’
When you talk to them, it’s clear they have depression.”
For some doctors, coaching patients through personal
crises can seem a waste of the specialty they studied. For oth-
ers, prescribing behavioral medicines can strain their own
nerves. “They just don’t have the confidence,” Dickson says
of colleagues who refer their patients to her for prescriptions
they could easily handle. “They don’t want to touch it.”
Dickson embraced the dualities inherent in the profession
by completing a double-residency in general practice and
psychiatry. In a small town like Glendive, this gives her an
enormously broad window into the lives around her, and some-
times it can seem as if she knows everything about all of her
neighbors. She’s got a pretty good handle on who was abused
as a child, whose marriage is on the rocks, who’s flirted with
an addiction to painkillers, who’s skittering through a mid-life
crisis. It’s the sort of knowledge that can apply pressure on a
person. She has no colleagues to talk with about possible treat-
ments, no one to commiserate with over coffee. The American
Psychiatric Association used to have a special committee ded-
icated to rural mental health providers, and she belonged to
it, but the group disbanded a few years back. “There weren’t
enough of us,” she says.
The absence of professional models means that she has
been forced to create her own makeshift code of professional
standards, because the ones her urban counterparts follow
simply don’t apply. “The ethics of psychiatry are very strict, as
far as you shouldn’t be doing business with someone who’s a
patient of yours, for example,” she says. “Well, if that were the
case, I wouldn’t be able to have my car fixed, buy my espresso
in the morning, have a hamburger at lunch....”
It’s a Monday morning, post-espresso, and she’s sitting at
her desk. The dog is tirelessly angling for her attention, drop-
ping a squeeze ball in front of her on the desk, staring at her
expectantly. Without looking away from the screen, Dickson
tosses the ball into the waiting room; Jemma chases it, brings
it back. Dickson absently humors the dog as she reads her
screen, tossing the ball again and again, until her phone rings.
She says hello and instantly recognizes the male voice that
comes through the speaker—a longtime client, one of hun-
dreds who’s unafraid to call when life seems to be taking an
unhealthy turn. “Oh,” he says, drawing a deep breath, “am
I glad to hear your voice. I’m kinda jammed up here.” She
takes him off speaker, and her first informal consultation of
the week begins.3
DICKSON RECENTLY SURVEYED
her patients to see why they thought this region, out
of all the places in America, had become a hot zone
in the suicide epidemic. Many blamed the Native American
reservations, which they associate with addiction and despair.
Those populations do, it’s true, have unusually high rates ofdepression and suicide, but Dickson challenged the answer as
insufficient; even if you excluded those areas, the state’s sui-
cide rate would still be among the nation’s highest. Montana’s
Department of Public Health and Human Services last year
reported a 2017 survey that suggested about 15% of all seventh-
and eighth-grade students in the state had attempted sui-
cide one or more times in the preceding 12 months. (Among
Native American students, the figure was slightly higher, at
18%.) It’s a frighteningly high number and helped spur new
outreach programs in the schools, but the suicide problem
is even worse among adults. The average suicide victim in
Montana is a middle-aged white male.
It’s impossible to pin down a primary cause, or even a
set of them, but rural isolation is often fingered as a culprit.
Suicides are worse here in the winters, supporting the
hypothesis: For several months of the year, the region is
gray, snowy, and bitterly cold, and the social pulse, meta-
bolically subdued even in the summer, slackens noticeably.
But isolation is nothing new here. Way back in 1893, a writer
for the Atlantic Monthly observed that the “silence of death”
cloaked the desolate landscape west of the Dakotas, and that
“an alarming amount of insanity” haunted the pioneers who
chose to homestead there.
When Dickson asked one of her longtime family practice
patients why he thought there was so much mental illness
in the area, he dismissed the notion outright. “First, you
gotta believe that mental illness is a thing,” he told her. “And
I don’t. You just get over it and move on.” It was a succinct dis-
tillation of the “cowboy up” gospel—a local creed that reveresTHE BILLINGS CLINIC44